Everything You Need to Know About Golfer's Elbow (From a PT)

“How do I have Golfer’s Elbow?  I don’t even golf!”

Whether you golf or not, you can end up with Golfer’s Elbow.  Think you might have it? Whatever you do, don’t ignore it. Wondering how to fix it?  Keep on reading!

What is Golfer's Elbow (aka Golf Elbow) & What Causes It?

Golfer’s Elbow often starts off as a pain on the inside of the elbow (the part of your elbow closest to your body when your arms are down by your side).

If left untreated, the pain can spread up to the neck or down to the fingers.  In severe cases, people may start to notice swelling, tingling in the forearm and fingers, or even numbness.  Gripping is usually painful.

Golfer’s Elbow is also known as medial epicondylitis, or more recently referred to as medial epicondylalgia.  “Medial” refers to the fact that it is on the inside of the elbow and “epicondylalgia” refers to pain at the epicondyle, where the flexor tendons of the forearm attach to the humerus (arm bone).

In other words, the name of this diagnosis refers primarily to the location of the pain.  When there is a tear present it is usually in the flexor carpi radialis/pronator teres tendon.

Not all cases of Golfer’s Elbow are due to a tear in the tendon.  This is a common cause of the pain but there are other reasons someone might have pain near the medial epicondyle of the elbow.  Sometimes it is chronic inflammation in the area from repeated stress that is causing the pain and sometimes it is “radiculopathy” from the neck.  We will get into this more later but “radiculopathy” means that the pain is radiating down the arm in a specific path due to a dysfunction in the cervical spine.  

Golfer’s Elbow is not always caused by playing golf! In fact, it can be caused by any number of sports - tennis, pickleball, you name it.  It can also be caused by normal daily activities such as cooking, cleaning, typing on a keyboard. Why on earth would you get injured doing normal daily activities? Well, because there is an underlying movement dysfunction taking place.  Likely due to a muscle imbalance or poor posture. We will talk more about this later as well, so hold your horses.

What’s the Difference Between Golfer’s Elbow & Tennis Elbow?

Golfer’s Elbow and Tennis Elbow are very similar conditions.  The primary difference between the two is the location of the pain.  As we discussed earlier in this article, Golfer’s Elbow is pain at the medial epicondyle (the inside of the elbow).  Tennis Elbow on the other hand is pain at the lateral epicondyle (outside of the elbow); this is why it is often called “lateral epicondylitis” or “lateral epicondylalgia”.

Golfer’s Elbow affects the flexor tendons whereas Tennis Elbow affects the extensor tendons of the forearm.  Both groups of muscles control the motion of the wrist, which is why doing gripping activities (such as gripping a tennis racket or a golf club) can aggravate the symptoms.



Symptoms of Golfer’s Elbow & Tests You Can Do to See If You Have It

 

How can you tell if you have Golfer’s Elbow?  Here are a couple of simple tests you can do at home:

  1. This one tests to see if you have pain with contracting your wrist flexor muscles...Extend your arm out in front of you and pick up a gallon of milk or something equally as heavy with a straight elbow.  If you have pain on the inside of the elbow (near the elbow bone) you could have Golfer’s Elbow.
  2. This one tests to see if you have pain with stretching your wrist flexor muscles...Extend your arm out in front of you with your elbow straight and your palm facing up.  Then with the other hand slowly pull the fingers of your extended arm down towards the floor (extending your wrist) while keeping the elbow straight.  If you have pain on the inside of the elbow (near the elbow bone) you could have Golfer’s Elbow.

Golfer’s Elbow can cause a variety of symptoms:

-Constant or intermittent pain on the inside of the elbow

-Constant or intermittent pain that radiates from the elbow up to the shoulder/neck or down to the fingers

-Weakening grip

-Feeling of fatigue or heaviness in the forearm and hand

-If the nerves that pass through the elbow become involved, you may also notice nerve pain or paresthesias (such as numbness or tingling in your fingers

You should not experience bruising with Golfer’s Elbow unless you experienced a trauma resulting in your injury.  This is different than slowly acquiring Golfer’s Elbow over time.  An example of a trauma is a guy goes out golfing pain-free and then on Hole #4 he swings and “OUCH!”  He felt it immediately, maybe he even heard a pop. He notices swelling and bruising. This is a traumatic injury.  Most people do not acquire Golfer’s Elbow in this way therefore they should not have bruising associated with their injury.

Golf Elbow Treatment Options

There are a variety of treatment options that range from very conservative (no risk involved) to very invasive (much more risk involved).  On the most conservative end we have rest. It is unlikely you are going to further injure yourself by resting. On the most invasive end of the spectrum we have surgery.  Further injury is inevitable as at least one small incision needs to be made to have surgery and you will likely have general or local anesthesia that comes with it’s own risks of course.  

There are many different forms of treatment that fall on the spectrum somewhere between rest and surgery.  Below we will discuss some of the more conservative treatments (such as exercise) and some of the more invasive treatments (such as injections).

Stretches & Strengthening Exercises

We’re going to go over stretching and strengthening first because even though it takes the most time and effort of all treatment options it is the most effective treatment option for Golfer’s Elbow.  Stretching is crucial because as your body heals the tendon it lays down scar tissue. We want to make sure this new tissue has good stretch tolerance so that it doesn’t tear again. The new scar tissue only has about 80% of the strength that the original tissue has, so it’s that much more important that we do what we can to reduce the risk of reinjury in the future.  For this reason, stretching is a vital activity for people of all ages and activity level… unless you want to have that Golfer’s Elbow come back in a couple of years. I’m guessing you don’t, so get stretching!

Strengthening should not be underestimated.  Many of us think of doing bicep curls and squats when we think of strength training; but what about strengthening the rotator cuff of the shoulder, the scapular stabilizers, or the wrist pronators?  You probably haven’t ever focused on these areas and these are the areas that most people with Golfer’s Elbow need to zoom in on.

There are specific stretches and specific strengthening exercises that should be done….

Braces, Tape, and Compression Sleeves

I’ve had many of my clients feel that their symptoms were caused by the nature of their job.  Maybe they’re landscapers or perhaps they spend their days typing on a keyboard. Many people can’t take enough time off work to fully heal from Golfer’s Elbow before returning to their job.  

If this sounds like you, you may want to invest in a brace, strap, or compression sleeve.  Or perhaps you would prefer to learn a taping technique. These accessories do not heal your injury but they do help reduce your symptoms and reduce the risk of further re-injury if worn during activities that you know aggravate your symptoms. For many people, wearing a brace is the only way they can continue to work while healing from their injury.  

How do they work?  Think of it this way… if I fall down and break my leg the doctor will put a cast on it.  The cast itself doesn’t heal my leg but it does protect my leg so that I can go about my daily life without further re-injury.  This allows my leg to heal as fast as possible. Braces, tape, compression sleeves and straps act in a similar way.

Physical Therapy

Physical therapy (PT) is an excellent option for treatment of tennis elbow.  Your physical therapist will likely evaluate you on the first day and then develop a treatment plan consisting of exercise, manual therapy, and patient education.  Your treatment will usually start at the next follow up visit. You will be given a home exercise program. It’s very important that you do these exercises! You won’t get better just by walking into the physical therapy clinic.  It depends on your insurance and the state that you live in but you often need to get a physician referral to see a physical therapist.

Unfortunately in the U.S. paying for physical therapy can be a great challenge with sky high deductibles and large copays. If you have insurance, call the number on the back of your insurance card to inquire what they will pay for.  

Massage

Massage is a form of manual therapy that is key to a speedy recovery.  Whether you choose to get a professional massage, have a friend or family member give you a massage, or do self-massage, you will find that the treatment (usually) helps to reduce pain and tension and expedite healing.  Massage improves blood flow which helps bring oxygen and other microscopic goodies to the area to help damaged tissues repair faster. Massage is known to help bring essential hormones - such as human growth hormone - to the area and stimulate nerves that may be “off the map”.  Waking these nerves up can allow your body to utilize your muscles properly, which can help reduce strain on tendons. Long story short, massage is amazing so get rubbing!

If you choose to go get a massage from a licensed massage therapist (LMT) ask if they take insurance.  Some insurance companies will pay for several visits a year, though this is rare. A 60 minute massage usually costs anywhere from $50-100.  Don’t forget to tip!

Natural Treatments & Supplements

Some people choose to try natural topical remedies such as castor oil and CBD oil.  Castor oil contains ricinoleic acid, which has traditionally been used to treat a wide variety of ailments including inflammation. CBD oil also has anti-inflammatory properties.  If you’re going to massage your Golfer’s Elbow why not use these oils as well? They may help reduce your symptoms. It’s important to remember however, that these oils alone will not treat the root of the problem.

There are many supplements out there that claim to heal tendons, maybe hundreds. And I’m sure some of them truly do help!   The issue with the supplement industry is that there aren’t many third parties testing the contents of the supplements. In other words there is no regulating body making sure that the Magic Tendon Healing Pills you bought have anything of value in them, or even have what they claim to have in them.  The pill bottle can say it has one thing in it but in fact have something entirely different in it. It’s the sad truth. However, there are reputable supplement brands out there so do your research!

I’ve had many of my patients tout the benefits of taking collagen to help heal an injured tendon.  This has good research backing it up as well. It makes sense, our tendons are made up of collagen fibers so what better place to get all of the components you need to make collagen fibers than collagen?  

Some people prefer to get the majority of their nutrients from food sources rather than supplements.  I love food so I fall into this category. I would rather eat my nutrients than wash them down in a tasteless capsule.  If you’re like me, collagen is present in many foods but there are particularly high levels in bone broth and chicken skin.

Another thing to consider when trying to recover from a case of Golfer’s Elbow is avoiding inflammatory foods.  Inflammatory foods can vary a bit person to person but there is one category of food that is known to cause inflammation in everyone… sugar.  It’s probably not surprising to you but even small amounts of sugar can have dramatic effects on the entire body. I’ve had patients who struggled with chronic debilitating joint pain and muscle aches.  They decided to go on a strict diet with as little sugar as possible (this means no carbs) and their pain went away completely after 1-2 months. This is not an easy thing to do, but I would try it before letting someone cut into me.  The best part? There are absolutely no risks involved (unless you are diabetic, in which case you can still try it but you would likely need physician supervision and monitor your blood sugar levels closely).

Anti-Inflammatories: Pros and Cons

Pros:

~ they really do decrease inflammation!

~ they might help you continue to work or do what you need to do to get through your day without tremendous pain

Cons:

~ possible adverse effects (ex: developing a stomach ulcer)

~ possibility of delaying healing (more on this below…)

There are several kinds of anti-inflammatory drugs available for treatment of Golfer’s Elbow.  There are prescription strength drugs, over the counter (OTC) drugs, and supplements (such as tumeric) touting anti-inflammatory properties.  

Some of the most common prescription strength anti-inflammatories are meloxicam and naproxen.  Depending on your insurance these may or may not be costly. Most are not know to be addictive but they always come with a long list of possible adverse effects that you want to make sure you read before you start taking the pills.  

Probably the most common OTC drug people take to treat Golfer’s Elbow is ibuprofen.  Since you can purchase ibuprofen at any pharmacy in any town in any state without batting an eye it might seem completely harmless.  The reality is however, the FDA has given ibuprofen a Black Box Warning. This is the highest warning the FDA can place on a drug due to the fatalities associated with the drug.  Ibuprofen has a warning placed because it increases the user’s risk of having a stroke, heart attack, and severe gastrointestinal bleed. It’s a serious bummer.

There has been a bit of controversy about anti-inflammatories used for treatment of  non-arthritic conditions (such as Golfer’s Elbow). A certain amount of inflammation as part of a very complex chemical pathway is essential for healing damaged tissue.  Anti-inflammatory drugs can disrupt this pathway and therefore can stall healing. I don’t personally know the truth of this matter but if it were me, I would probably stick to just using ice to help control swelling and pain.  There are fewer risks involved with using ice and it’s free!

Cortisone Injections: Pros and Cons

Pros:

~it may relieve your symptoms forever!

~it is quick and easy

~it doesn’t require a very long recovery time

Cons:

~it may not relieve your symptoms or it may only relieve them for a short period of time

~your condition could return worse than before the shot

~possible adverse effects (such as:  joint infection, nerve damage, thinning of skin, and more…)

On the spectrum of “conservative” to “invasive” treatments for Golfer’s Elbow cortisone injections are certainly on the more invasive side, only to be beaten by surgery.  Cortisone injections contain corticosteroids and sometimes extra shorter-lasting ingredients such as analgesics.

Corticosteroids weaken tissue, which isn’t really what we want when we have Golfer’s Elbow and we’re trying to heal an injured tendon...I’ve had many, many, many patients get a cortisone injection before coming to me for physical therapy and unfortunately many of them wish they never got it.   Studies show that those who get cortisone injections have a significantly higher chance of being in more pain 6 months to a year later compared to those who did not get an injection.

For some people, I truly believe it is a decent choice to receive the injection.  If you have exhausted all of your other options for more conservative treatments such as rest, exercise, and changing your diet, and you still aren’t getting better, it may be worth a try!  If you’re insistent on getting one, I would advocate for an ultrasound guided injection to make sure it’s injected in the right spot.

Surgery: Pros and Cons

When all else fails… surgery may be your best option!

Pros:

~ it may relieve your symptoms

~ you might get a couple months to take off work and just lay on the couch and binge watch Netflix (for some that might be more of a con…)

~ you will get to go to physical therapy for 4-12 weeks to rehab the tendon and physical therapists are pretty awesome (in my unbiased opinion)

Cons:

~ all of the normal risks that are associated with surgery (infection, permanent damage to nerves or blood vessels, etc.)

~ possibly very expensive if your insurance does not cover it

Having surgery to fix your Golfer’s Elbow is obviously the most invasive treatment option.  Always get a second opinion if your physician suggests this and always know what exactly you are having repaired and why.  I can’t tell you how many of my patients have agreed to “exploratory surgery” and the surgeon didn’t find anything to fix! I know, it’s horrifying but it really happens.  

Most people do not really need surgery unless they have a true tear in the flexor carpi radialis/pronator teres tendon.  And just because you have a tear doesn’t necessarily mean you will need surgery. A relatively small tear (partial thickness) does not need to be operated on.  A larger tear or complete tear (full thickness) of the tendon does. Make sure you get an ultrasound or MRI prior to surgery to get an accurate-as-possible assessment before you go under the knife.  

Exercises & Activities to Avoid if You Have Golfer’s Elbow

In physical therapy we have a term called “relative rest”.  As physical therapists we recognize that when you get injured you can’t press the pause button on your life and lay down until you’re fully healed.  There are some activities we just have to do.  Relative rest simply means try to do less than what you were doing before you developed Golfer’s Elbow.  

This is really going to depend on you.  If it hurts, don’t do it. If everything hurts, avoid the activities that hurt the most.  If you can’t avoid the activities that hurt (because it is your job to do that activity, for example) then see the section above on wearing a brace or compression strap.  

Common activities that people choose to avoid because they aggravate the injured tendon:

-typing

-lifting/carrying heavy objects

-driving

-chopping food

-racquet sports

Final Thoughts: What’s the Outlook for People with Golfer’s Elbow & What’s the Typical Recovery Time?

In truth, the prognosis for Golfer’s Elbow is good… IF... you keep your hopes up and you stay consistent with your treatment program.

Here's what we learned:

  • Doing a stretch once every 3 weeks isn’t going to help.
  • Massaging for a few seconds every few days isn’t going to help.
  • Wearing a compression band for a couple hours at work one day isn’t going to help.  
  • Find a treatment regime that works for you and stick with it for 6-8 weeks before deciding to make a change.

The longer you have had Golfer’s Elbow the longer it will likely take you to recover from Golfer’s Elbow.  This is true for any injury.

Your body makes physiological changes to compensate when you have an injury and it takes time to reverse these changs.  Patience is key.

If you find yourself getting discouraged try taking note of small changes because those small changes add up.  

Being able to lift your coffee cup up for the first time after a few months might not seem like a huge deal but in the world of healing tendons, it’s a sign you’re on the right track!  

Keep it up. :)

 


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